(Week 1) FE: Balance and Disturbance

Question 1

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?

Nutritional status
Potassium balance
Calcium balance
Fluid volume status

Answer 1

Fluid volume status

Question 2

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

Diminished deep tendon reflexes
Tachycardia
Cool, clammy skin
Acute flank pain

Answer 2

Diminished deep tendon reflexes

Question 3

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

Metabolic alkalosis
Hypermagnesemia
Hypercalcemia
Hypovolemia

Answer 3

Hypovolemia

Question 4

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance?

Respiratory acidosis
Respiratory alkalosis
Increased PaCO2
CNS disturbances

Answer 4

Respiratory alkalosis

Question 5

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterialblood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

Respiratory acidosis with no compensation
Metabolic alkalosis with a compensatory alkalosis
Metabolic acidosis with no compensation
Metabolic acidosis with a compensatory respiratory alkalosis

Answer 5

Metabolic acidosis with a compensatory respiratory alkalosis

Question 6

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

Air emboli
Phlebitis
Infiltration
Fluid overload

Answer 6

Infiltration

Question 7

You are performing an admission assessment on an older adult patient newly admitted for end-stageliver disease. What principle should guide your assessment of the patients skin turgor?

Overhydration is common among healthy older adults.
Dehydration causes the skin to appear spongy.
Inelastic skin turgor is a normal part of aging.
Skin turgor cannot be assessed in patients over 70.

Answer 7

Inelastic skin turgor is a normal part of aging.

Question 8

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Choose a hairless site if available.
Consider potential effects on the patients mobility when selecting a site.
Have the patient briefly hold his arm over his head before insertion.
Leave the tourniquet on for at least 3 minutes.

Answer 8

Consider potential effects on the patients mobility when selecting a site.

Rationale:
Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.

Question 9

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

Hydrostatic pressure
Osmosis and osmolality
Diffusion
Active transport

Answer 9

Osmosis and osmolality

Rationale:
Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

Question 10

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Hypophosphatemia
Hypocalcemia
Hypermagnesemia
Hyperkalemia

Answer 10

Hypocalcemia

Rationale:
Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

Question 11

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?

The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
The kidneys buffer acids through electrolyte changes.
The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Answer 11

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

Rationale:
The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

Question 12

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?

Hypercalcemia
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis

Answer 12

Metabolic alkalosis

Rationale:
Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status.

Question 13

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

Leave one hand ungloved to assess the site.
Cleanse the skin with normal saline.
Ask the patient about allergies to latex or iodine.
Remove excessive hair from the selected site.

Answer 13

Ask the patient about allergies to latex or iodine.

Question 14

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis

Answer 14

Respiratory acidosis

Question 15

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over15 minutes. This intervention will achieve which of the following?

Help distinguish hyponatremia from hypernatremia
Help evaluate pituitary gland function
Help distinguish reduced renal blood flow from decreased renal function
Help provide an effective treatment for hypertension-induced oliguria

Answer 15

Help distinguish reduced renal blood flow from decreased renal function

Rationale:
If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

Question 16

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup.

Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.

It is normal to be a little confused following surgery, and it is safe not to urinate at night.

If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Answer 16

Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.

Question 17

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.

The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.

The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.

The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosteronesystem that results in diminished urine output.

Answer 17

The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosteronesystem that results in diminished urine output.

Rationale:

Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.

Question 18

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

Leave the hair intact.
Shave the area.
Clip the hair in the area.
Remove the hair with a depilatory.

Answer 18

Clip the hair in the area.

Rationale:
Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

Question 19

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium
Decreased serum potassium
Decreased hemoglobin
Increased platelets

Answer 19

Increased serum sodium

Rationale:
Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

Question 20

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

The patients calcium will rise dramatically due to pituitary stimulation.
Oxygen will increase the patients intracranial pressure and create confusion.
Oxygen may cause the patient to hyperventilate and become acidotic.
Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia

Answer 20

Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia

Rationale:
When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Question 21

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

Diffusion
Osmosis
Active transport
Filtration

Answer 21

Diffusion

Question 22

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causesthis to occur?

Active transport of hydrogen ions across the capillary walls
Pressure of the blood in the renal capillaries
Action of the dissolved particles contained in a unit of blood
Hydrostatic pressure resulting from the pumping action of the heart

Answer 22

Hydrostatic pressure resulting from the pumping action of the heart

Question 23

The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes inthe circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

Decrease in the release of aldosterone
Increase of filtration in the Loop of Henle
Decrease in the reabsorption of sodium
Decrease in glomerular filtration

Answer 23

Decrease in glomerular filtration

Rationale:
Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption.

Question 24

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?

Substantially reduced renal function
Acute kidney injury
Decreased cardiac output
Alterations in ratio of body fluids to muscle mass

Answer 24

Substantially reduced renal function

Rationale:
Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acid-base disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults.

Question 25

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. Youstart the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

Extravasation of the medication
Discomfort to the patient
Blanching at the site
Hypersensitivity reaction to the medication

Answer 25

Extravasation of the medication

Rationale:
Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.

Question 26

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit?

Diarrhea
Dilute urine
Increased muscle tone
Joint pain

Answer 26

Dilute urine

Rationale: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.

Question 27

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancerwith bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

Hypernatremia
Hypomagnesemia
Hypophosphatemia
Hypercalcemia

Answer 27

Hypercalcemia

Rationale: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present.

Question 28

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
The kidneys react rapidly to compensate for imbalances in the body.
The kidneys regulate the bicarbonate level in the intracellular fluid.

Answer 28

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

Question 29

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

Endocarditis
Multiple myeloma
Guillain-Barr syndrome
Overdose of amphetamines

Answer 29

Guillain-Barr syndrome
Rationale:
Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute
respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barr syndrome.

Question 30

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Mixed acid-base disorder

Answer 30

Mixed acid-base disorder

Rationale: Patients can simultaneously experience two or more independent acidbase disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3 concentration immediately suggests a mixed disorder, making the other options incorrect.

Question 31

A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

Never, because it rapidly enters red blood cells, causing them to rupture.
When the patient is severely dehydrated resulting in neurologic signs and symptoms
When the patient is in excess of calcium and/or magnesium ions
When a patients fluid volume deficit is due to acute or chronic renal failure

Answer 31

Never, because it rapidly enters red blood cells, causing them to rupture.

Rationale: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte- free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture.

Question 32

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply.

Decreased kidney mass
Increased conservation of sodium 
Increased total body water
Decreased renal blood flow
Decreased excretion of potassium

Answer 32

Decreased kidney mass
Decreased renal blood flow
Decreased excretion of potassium

Rationale: Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

Question 33

You are called to your patients room by a family member who voices concern about the patients status.On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

Hypocalcemia
Hyponatremia
Hyperchloremia
Hypophosphatemia

Answer 33

Hyperchloremia

Rationale: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.

Question 34

Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?

Metastases
Excessive potassium intake
Water intoxication
Excessive administration of chloride

Answer 34

Excessive administration of chloride

Rationale: Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

Question 35

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?

Cimetidine
Maalox
Potassium chloride elixir
Furosemide

Answer 35

Cimetidine

Rationale: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction.

Question 36

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?

Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.

Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.

Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.

Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Answer 36

Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.

Rationale:
The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

Question 37

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital.The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply.

Milk
Beef
Poultry
Green vegetables
Liver

Answer 37

Milk
Poultry
Liver

Rationale: If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.

Question 38

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

Hypertension
Kussmaul respirations
Increased DTRs
Shallow respirations

Answer 38

Shallow respirations

Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.

Question 39

A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium?

Apples
Asparagus
Carrots
Bananas

Answer 39

Bananas